Citation Nr: 18150830 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-21 354 DATE: November 15, 2018 ORDER The application to reopen the claim of service connection for right hip disability is denied. The application to reopen the claim of service connection for right knee disability is denied. Entitlement to an effective date earlier than May 24, 2013 for the award of service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for right ankle disability is denied. REMANDED Entitlement to service connection for neck disability is remanded. Entitlement to service connection for back disability is remanded. Entitlement to service connection for left hip disability is remanded. Entitlement to service connection for left leg disability is remanded. Entitlement to service connection for left ankle disability is remanded. Entitlement to service connection for right foot disability, to include status post right great toe fracture and right foot drop, is remanded. Entitlement to service connection for cardiac disability is remanded. Entitlement to service connection for prostate disability is remanded. Entitlement to an initial rating higher than 30 percent for PTSD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. A claim of service connection for psychiatric disability (characterized as nervous condition) was initially denied in an April 1972 rating decision on the basis that there was no evidence of any such disability related to service; additional relevant evidence was received following the initial April 1972 decision and the claim of service connection for psychiatric disability was readjudicated and again denied in a later April 1972 decision; the Veteran did not appeal either April 1972 decision within one year of its issuance and new and material evidence was not received within the year following the issuance of the second April 1972 decision. 2. The Veteran’s claims of service connection for right hip disability and right knee disability were originally denied in a January 2007 rating decision on the basis that these disabilities were not incurred in service and that the right knee disability was not associated with a service-connected disability; the Veteran submitted a timely notice of disagreement (NOD) in February 2007 and a statement of the case (SOC) was issued in June 2007, but the Veteran did not file a substantive appeal. 3. The claims of service connection for right hip disability and right knee disability were again denied in an August 2008 rating decision on the basis that new and material evidence had not been received; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 4. An application to reopen the claim of service connection for psychiatric disability was received on May 24, 2013; there is no evidence of any unadjudicated formal or informal application to reopen the claim of service connection for psychiatric disability after the second April 1972 decision, but prior to May 24, 2013. 5. Evidence received since the August 2008 agency of original jurisdiction (AOJ) decision includes information that was not previously considered, but which does not relate to an unestablished fact necessary to substantiate the claims of service connection for right hip disability and right knee disability. 6. The preponderance of the evidence is against finding that the Veteran has right ankle disability due to a disease or injury in service. CONCLUSIONS OF LAW 1. The AOJ’s April 1972, January 2007, and August 2008 rating decisions that denied the claims of service connection for psychiatric disability, right hip disability, and right knee disability are all final. 38 U.S.C. § 7105 (a), (b)(2), (d)(3); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.32, 20.200, 20.302, 20.1103. 2. The evidence received since the August 2008 AOJ decision is not new and material and, therefore, insufficient to reopen the claims of service connection for right hip disability and right knee disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The criteria for an effective date earlier than May 24, 2013 for the award of service connection for PTSD are not met. 38 U.S.C. §§ 5110 (a), 7105(d)(3); 38 C.F.R. §§ 3.104, 3.155 (in effect prior to March 24, 2015), 3.156(a)-(b), 3.400, 20.302, 20.1103. 4. The criteria for service connection for right ankle disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1965 to August 1967, which includes service in the Republic of Vietnam. His awards include the Combat Infantry Badge. These matters come before the Board of Veterans’ Appeals (Board) from an August 2014 rating decision. As for characterization of the issues on appeal, the Board notes that the AOJ characterized the right hip and right knee issues on appeal as entitlement to service connection for right hip disability and right knee disability. As explained in more detail below, claims of service connection for right hip disability and right knee disability were most recently denied by way of a final August 2008 rating decision. Hence, the Board must initially determine whether new and material evidence has been submitted with regard to the claims of service connection for right hip disability and right knee disability. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Only where the Board concludes that new and material evidence has been received does it have jurisdiction to consider the merits of these claims. Hickson v. West, 11 Vet. App. 374, 377 (1998). Accordingly, the Board has recharacterized the right hip and right knee issues as whether new and material evidence has been received to reopen the claims of service connection for right hip disability and right knee disability. Also, in light of the Veteran’s reported symptoms and contentions and to encompass all disorders that are reasonably raised by the record, the Board has recharacterized the separate claims of service connection for status post right great toe fracture and right foot drop as a claim of service connection for right foot disability, to include status post right great toe fracture and right foot drop. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim). Additionally, the Veteran has been retired during the claim period pertaining to his appeal for a higher initial rating for PTSD and there is evidence that he is unable to maintain gainful employment due to his service-connected psychiatric disability. Entitlement to a TDIU may be an element of an appeal for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Given the evidence of a current disability, the Veteran’s claim for the highest rating possible for his service-connected psychiatric disability, and the evidence of unemployability, the issue of entitlement to a TDIU is properly before the Board under Roberson and Rice and the Board has expanded the appeal to include this issue. As a final preliminary matter, the Board points out that the Veteran filed a timely NOD with a February 2017 rating decision, in which the AOJ denied service connection for aseptic necrosis, multiple myeloma, and renal failure. In a March 2017 letter, the AOJ acknowledged that the Veteran’s NOD was received. Moreover, the Veterans Appeals Control and Locator System (VACOLS) shows that the AOJ has acknowledged receipt of the NOD and that additional action is pending. As such, this situation is distinguishable from that in Manlincon v. West, 12 Vet. App. 238 (1999) (now codified at 38 C.F.R. § 19.9(c), where an NOD had not been recognized. As the Veteran’s NOD with the February 2017 rating decision has been acknowledged by the AOJ and further action is pending, the Board declines to remand the issues adjudicated in the February 2017 rating decision for issuance of an SOC. Rather, these issues may be the subject of a future Board decision, if necessary. I. Applications to Reopen Generally, an AOJ decision denying a claim which has become final may not thereafter be reopened and allowed. 38 U.S.C. § 7105 (d)(3). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). For the purpose of determining whether new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The application to reopen the claims of service connection for right hip disability and right knee disability As a preliminary matter, the Board notes that the Veteran has not been afforded VA examinations to assess the nature and etiology of his claimed right hip disability or right knee disability, and medical opinions addressing the etiology of these claimed disabilities have not otherwise been obtained. However, the duty to obtain an examination or medical opinion under 38 C.F.R. § 3.159 (c)(4) applies to a claim to reopen only if new and material evidence is presented or secured. Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003) (holding that VA need not provide a medical examination or medical opinion until a claim is reopened); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (holding that adequacy of VA medical examination mooted upon Board’s determination that claimant not entitled to reopening of claim). As explained below, the Board finds that no new and material evidence has been received with respect to the claims of service connection for right hip disability or right knee disability. Hence, VA examinations and/or opinions are not necessary in this instance. The Board finds, for the following reasons, that new and material evidence pertaining to the claims of service connection for right hip disability and right knee disability has not been received and that, accordingly, these claims may not be reopened. The Veteran’s claims of service connection for right hip disability and right knee disability were originally denied in a January 2007 rating decision on the basis that these disabilities were not incurred in service and that the right knee disability was not associated with a service-connected disability. Specifically, the AOJ explained that there was evidence of treatment for left knee problems in the Veteran’s service treatment records, but that there was no evidence of any treatment for knee or right hip problems in service and there was no evidence that the claimed right hip and right knee disabilities were otherwise incurred in service. Also, although the Veteran claimed that his right knee disability was secondary to his right hip disability, service connection for the right knee disability could not be established on a secondary basis because service connection for the claimed right hip disability was not established. The Veteran submitted a timely NOD with the January 2007 decision in February 2007 and an SOC was issued in June 2007. Appellate review is initiated by an NOD and completed by a substantive appeal filed after an SOC has been furnished to an appellant. 38 U.S.C. § 7105 (a); 38 C.F.R. § 20.200. A substantive appeal must be filed within 60 days from the date of mailing of an SOC, or within the remainder of the one-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 U.S.C. § 7105 (b)(2); 38 C.F.R. § 20.302 (b). In the absence of a properly perfected appeal, the AOJ may close the appeal and the decision becomes final. 38 U.S.C. § 7105 (d)(3); Roy v. Brown, 5 Vet. App. 554, 556 (1993); 38 C.F.R. § 19.32. The AOJ did so in this case, as evidenced by a May 2008 letter sent to the Veteran, which informed him that he did not submit a timely substantive appeal following the issuance of the June 2007 SOC and that no further action could be taken with respect to his appeal. Also, the AOJ did not certify to the Board the issues of entitlement to service connection for right hip disability and right knee disability following the June 2007 SOC. The Veteran did not appeal the AOJ’s May 2008 decision within one year of its issuance. As neither the Veteran nor his representative submitted any document that could be construed as a timely substantive appeal pertaining to the claims of service connection for right hip disability and right knee disability following the June 2007 SOC, the AOJ closed the appeal. The AOJ did not certify either of these issues to the Board at that time and no further action was taken by VA to suggest that either of these issues were on appeal. Thus, the January 2007 rating decision became final as to the denial of service connection for right hip disability and right knee disability. See 38 U.S.C. § 7105 (d)(3); Fenderson v. West, 12 Vet. App. 119, 128-31 (1999) (discussing the necessity of filing a substantive appeal which comports with governing regulations); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The claims of service connection for right hip disability and right knee disability were again denied in an August 2008 rating decision on the basis that new and material evidence had not been submitted. The Veteran was notified of the AOJ’s August 2008 decision, he did not appeal the decision within one year of its issuance, and new and material evidence was not received within that year. Therefore, the August 2008 decision also became final. See 38 U.S.C. § 7105 (d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. Pertinent to the claims of service connection for right hip disability and right knee disability, evidence added to the claims file since the August 2008 rating decision includes VA treatment records and various lay statements from the Veteran and his representative. This evidence reflects that the Veteran has continued to experience right hip and right knee disabilities. However, there is no new competent evidence that the claimed right hip or right knee disabilities had their onset in service, were manifest to a compensable degree within one year of the Veteran’s separation from service, are otherwise the result of a disease or injury in service, or are related to a service-connected disability. Overall, the Veteran has not submitted any new evidence indicating that his claimed right hip disability or right knee disability are related to service or service-connected disability, and neither he nor his representative has alluded to the existence of any such evidence. Also, to whatever extent the Veteran’s assertions are being offered to establish a nexus between his claimed disabilities and service or a service-connected disability, the Board acknowledges that he is competent to report his symptoms and history. Regardless, he is not competent in this instance to determine that his claimed disabilities were incurred in service or were caused or aggravated by a service-connected disability. This issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Hence, any new lay assertions that the claimed right hip disability or right knee disability is related to service or a service-connected disability are not competent evidence on this point, and, thus, cannot, alone, constitute new and material evidence to reopen the claims. Overall, the Board finds that the above-cited evidence is either duplicative or cumulative of the evidence previously of record, or, if new, is either not relevant to the claims of service connection for right hip disability or right knee disability, or does not provide a reasonable possibility of substantiating either claim. Under these circumstances, the Board concludes that, even when considering the “low threshold” for determining whether evidence is new and material pursuant to Shade v. Shinseki, 24 Vet. App. 110 (2010), the criteria for reopening the claims of service connection for right hip disability and right knee disability are not met. Furthermore, while VA has an obligation to assist the Veteran in the development of his claim, it is the Veteran’s responsibility to present and support a claim of service connection. 38 U.S.C. § 5107 (a); see also Skoczen v. Shinseki, 564 F.3d 1319, 1323 (Fed. Cir. 2009). As the Veteran has not identified or presented any new and material evidence pertaining to his claims of service connection for right hip disability or right knee disability, the application to reopen these claims must be denied. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claims under consideration, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). II. Earlier Effective Date Generally, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. VA amended its adjudication regulations on March 24, 2015 to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As the claim in this case was filed prior to that date, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015 will be applied in this case. Under the former legal authority, any communication or action, indicating an intent to apply for one or more benefits under laws administered by VA, from a veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155 (a) (in effect prior to March 24, 2015). There is no set form that an informal written claim must take. All that is required is that the communication indicates an intent to apply for one or more benefits under the laws administered by VA, and identify the benefits sought. Rodriguez v. West, 189 F.3d 1351 (1999). Entitlement to an effective date earlier than May 24, 2013 for the award of service connection for PTSD The Board finds, for the following reasons, that an effective date earlier than May 24, 2013 is not warranted for the award of service connection for PTSD. The current effective date for the award of service connection for PTSD is May 24, 2013, the date that the Veteran’s application to reopen the claim of service connection for psychiatric disability was received. The AOJ initially denied the Veteran’s claim of service connection for psychiatric disability (characterized as nervous condition) by way of an April 1972 rating decision on the basis that there was no evidence of any such disability related to service. Specifically, the AOJ explained that there was no evidence of or treatment for a nervous disorder during service and that there was no evidence of any current psychiatric disability during a VA psychiatric examination. The claims file includes an April 1972 “Disability Award” form (VA Form 21-6798), which indicates that a “Control Document and Award Letter” (VA Form 20-822) and an attached “Original Disability Compensation” form (VA Form 21-6782) had been processed and the decision addressed in these documents included the denial of service connection for psychiatric disability (identified as nervous condition). These documents serve as indicia of mailing and notification of the April 1972 rating decision as well as the Veteran’s appellate rights. Additional relevant VA treatment records were received and associated with the claims file in April 1972, following the issuance of the initial April 1972 rating decision. Thereafter, the claim of service connection for psychiatric disability was readjudicated and again denied in a second April 1972 rating decision. The Veteran was notified of the AOJ’s second April 1972 decision, he did not appeal the decision within one year of its issuance, and new and material evidence was not received within that year. Therefore, the April 1972 decision became final. See 38 U.S.C. § 7105 (d)(3); Bond, 659 F.3d at 1362; 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. The Veteran submitted an application to reopen the claim of service connection for psychiatric disability in May 2013. This application was received by the AOJ on May 24, 2013. The AOJ subsequently awarded service connection for PTSD by way of the August 2014 rating decision, from which the current appeal originates. The Board acknowledges that medical records dated after the April 1972 rating decision, but prior to the Veteran’s May 2013 application to reopen, indicate that he was treated for psychiatric symptoms. Under the former legal authority, 38 C.F.R. § 3.157 (b)(1) (in effect prior to March 24, 2015) provides that the date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. However, 38 C.F.R. § 3.157 (b)(1) “makes clear that a medical examination report will only be considered an informal claim for an increase in disability benefits if service connection has already been established for the disability. MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006); Massie v. Shinseki, 25 Vet. App. 123, 134 (2011), aff’d 724 F.3d 1325 (Fed. Cir. 2013) (§ 3.157(b)(1) requires that a report of examination or hospitalization indicate that the veteran’s service-connected disability worsened since the time it was last evaluated because, “[w]ithout such a requirement, every medical record generated by the Veterans Health Administration and received by VA that could possibly be construed as a report of examination would trigger the provisions of § 3.157(b)(1),” creating an unnecessary and unwarranted adjudicative burden on VA). This regulation is therefore not for application in connection with the instant claim. Moreover, the Board acknowledges that the Veteran’s service personnel records were associated with the claims file subsequent to the April 1972 rating decisions. VA regulations provide that, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding paragraph (a) of the same section (which defines new and material evidence). 38 C.F.R. § 3.156 (c). The regulation further identifies service records related to a claimed in-service event, injury, or disease as relevant service department records. 38 C.F.R. § 3.156 (c)(1)(i). In this case, the newly-associated service personnel records are not relevant to the claim of service connection for psychiatric disability, as they do not address whether there were any in-service psychiatric stressors or complaints associated with psychiatric disability, or whether there is any relationship between the Veteran’s claimed disability and service. Accordingly, reconsideration of the Veteran’s claim under 38 C.F.R. § 3.156 (c) is not required based upon the additionally-received service personnel records. Neither the Veteran, nor his representative, has presented any specific argument as to why an effective date earlier than May 24, 2013 is warranted for the award of service connection for PTSD. There is no evidence of any unadjudicated formal application to reopen the claim of service connection for psychiatric disability subsequent to the second April 1972 rating decision and prior to May 24, 2013, nor is there any prior communication in the record that could be considered an informal claim for VA compensation for the same. Thus, May 24, 2013 is the earliest possible effective date. See 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. Therefore, the Board finds that there is no basis upon which to justify granting an effective date earlier than May 24, 2013 and the appeal for an earlier effective date for the award of service connection for PTSD must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. III. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from a disease or injury incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for right ankle disability As a preliminary matter, the Board notes that the Veteran has not been afforded a VA examination for his claimed right ankle disability and an opinion as to the etiology of this disability has not otherwise been obtained. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. A claimant’s reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83. The types of evidence that “indicate” that a current disability “may be associated” with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. There must, however, be sufficient evidence of such a relationship to trigger VA’s duty to provide an examination or obtain a medical opinion. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). A conclusory generalized lay statement suggesting a nexus between a current disability and service is not sufficient, as this would, contrary to the intent of Congress, result in medical examinations being “routinely and virtually automatically” provided to all veterans claiming service connection. Id. at 1278-1279. In this case, there is no evidence that the current right ankle disability may be associated with service. As explained below, the Veteran has not reported, and the evidence does not otherwise reflect, a continuity of symptomatology with respect to this claimed disability. Also, there is no other competent evidence that the current right ankle disability may be related to service, and neither the Veteran nor his representative has alluded to the existence of any such evidence. Hence, a VA examination or opinion for the claimed right ankle disability is not necessary. See McLendon, 20 Vet. App. at 83. The question for the Board is whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the following reasons, the Board concludes that, while there is evidence that the Veteran has current right ankle disability (see e.g., a May 2013 VA primary care note which documents right ankle pain, tenderness, and swelling), the claimed disability has not been shown to have had its onset in service or to be otherwise related to a disease or injury in service. The Veteran has not reported, and the evidence does not otherwise reflect, that he has experienced a continuity of right ankle symptomatology in the years since service. In this regard, there is no evidence of any complaints of or treatment for right ankle problems in his service treatment records. Also, the evidence indicates that the current right ankle disability did not manifest until many years after service. The first evidence of right ankle problems is a March 2011 VA orthopedic surgery inpatient note which indicates that the Veteran was unable to flex or dorsiflex his ankle (most likely secondary to regional block) following right hip surgery. There is no earlier evidence of any right ankle problems. The absence of any evidence of right ankle problems for over four decades after the Veteran’s separation from active service in August 1967 is one factor weighing against a finding that his current right ankle disability was present in service or in the year or years immediately after service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue). Hence, neither the clinical record nor the lay statements of record establish a continuity of symptomatology with respect to the claimed right ankle disability. To the extent that the Veteran is attempting to establish nexus through his own opinion, the Board acknowledges that lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the question presented in this case (i.e., whether any relationship exists between the Veteran’s claimed right ankle disability and his military service) is a question as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). An opinion as to the link between the Veteran’s claimed right ankle disability and service, where there is no evidence of right ankle problems for decades after service, is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. There is no other evidence of a relationship between the Veteran’s claimed right ankle disability and service, and neither he nor his representative has alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran’s claimed right ankle disability had its onset in service or is otherwise related to service. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine is not for application, and the claim of service connection for right ankle disability must be denied. REASONS FOR REMAND 1. Entitlement to service connection for cardiac disability and prostate disability are remanded The Veteran contends that he has current cardiac and prostate disabilities that are related to service. His VA treatment records document that he has been diagnosed as having benign prostatic hypertrophy and a history of angina. Moreover, he is presumed to have been exposed to herbicide agents, including Agent Orange, during his service in Vietnam during the Vietnam War. Prostate cancer and ischemic heart disease are among the list of diseases that are presumed to be associated with exposure to certain herbicide agents. The Board cannot make a fully-informed decision on the issues of entitlement to service connection for cardiac disability and prostate disability because no VA examiner has opined whether the claimed disabilities were incurred in service. Hence, appropriate VA examinations should be scheduled upon remand. See 38 U.S.C. § 5103A (d); McLendon, 20 Vet. App. at 79. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Bay Pines VA Healthcare System (dated to March 2009) and the Miami VA Healthcare System (dated to December 2016). Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the remaining issues on appeal. A remand is required to allow VA to obtain them. 2. Entitlement to service connection for back disability is remanded. The Veteran contends that he has current back disability related to service. He was afforded a VA back examination in July 2014 and was diagnosed as having degenerative disk disease of the lumbar spine. The examiner who conducted the examination opined that the Veteran’s back disability was not likely related to service. This opinion is inadequate because the rationale that accompanies the opinion is absent of any consideration or discussion of the evidence of treatment for low back problems in May 1966, which is documented in the Veteran’s service treatment records. The Board cannot make a fully-informed decision on the issue of entitlement to service for back disability because no VA examiner has adequately opined as to the etiology of the Veteran’s current back disability. Thus, an appropriate medical opinion should be obtained upon remand. Also, a March 2005 VA treatment record suggests that the Veteran may have filed a workman’s compensation claim for a back injury. A remand is required to allow VA to obtain authorization and request any outstanding workman’s compensation records. Lastly, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to service connection for right foot disability, to include status post right great toe fracture and right foot drop, is remanded. The Veteran contends that he has current right foot disability (to include status post right great toe fracture and right foot drop) related to service. He was afforded a VA foot examination in July 2014 and was diagnosed as having right great toe fracture. The examiner who conducted the examination opined that the Veteran’s right foot disability was not likely related to service. This opinion is inadequate because the rationale that accompanies the opinion is absent of any consideration or discussion of the evidence of treatment for right foot injuries in September 1966 and June 1967, which are documented in the Veteran’s service treatment records. The Board cannot make a fully-informed decision on the issue of entitlement to service for right foot disability because no VA examiner has adequately opined as to the etiology of the Veteran’s current right foot disability. Thus, an appropriate medical opinion should be obtained upon remand. Also, all outstanding VA treatment records should be secured upon remand. 4. Entitlement to service connection for left leg disability is remanded. The Veteran’s VA treatment records reflect that he has experienced radicular symptoms associated with his back disability and that he has been diagnosed as having lumbar radiculopathy. Since a decision on the remanded issue of entitlement to service connection for back disability could significantly impact a decision on the issue of entitlement to service connection for left leg disability, the issues are inextricably intertwined. A remand of the claim for service connection for left leg disability is required. Also, all outstanding VA treatment records should be secured upon remand. 5. Entitlement to service connection for neck disability, left hip disability, and left ankle disability are remanded. As the record currently stands, there is no evidence of current neck disability, left hip disability, or left ankle disability. As additional treatment records are being sought upon remand which may document evidence of these claimed disabilities, the claims of service connection for neck disability, left hip disability, and left ankle disability are also being remanded. 6. Entitlement to an initial rating higher than 30 percent for PTSD is remanded. The evidence reflects that the Veteran’s service-connected psychiatric disability may have worsened since he was last examined by VA in July 2014. For instance, he submitted a February 2016 “Review Post Traumatic Stress Disorder Disability Benefits Questionnaire” (VA Form 21-0960P-3) which documents additional and/or more severe psychiatric symptomatology than was present at the time of the July 2014 VA psychiatric examination. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his service-connected psychiatric disability. Also, all outstanding VA treatment records should be secured upon remand. In this regard, a November 2016 VA psychiatry follow up assessment note reveals that the Veteran was scheduled for follow up psychiatric treatment on December 22, 2016. The most recent VA treatment records in the claims file are dated to December 16, 2016. 7. Entitlement to a TDIU due to service-connected disabilities is remanded. Since a decision on the remanded service connection and higher initial rating issues discussed above could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. The TDIU claim should be adjudicated in the first instance by the AOJ, to include appropriate notification and a request for the Veteran to submit a formal application for a TDIU (VA Form 21-8940). Also, all outstanding VA treatment records should be secured upon remand. The matters are REMANDED for the following action: 1. Send the Veteran a notice letter which provides him with notice as to the information and evidence that is required to substantiate his claim for a TDIU. A copy of this letter must be included in the file. 2. Ask the Veteran to complete a formal application for a TDIU (VA Form 21-8940) and to report his education and employment history and earnings, especially for the period since May 2013. 3. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for cardiac disability, prostate disability, left hip disability, left ankle disability, back disability, left leg disability, right foot disability, neck disability, and psychiatric disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records pertaining to any workman’s compensation claim and all records of his treatment for cardiac disability, prostate disability, left hip disability, left ankle disability, back disability, left leg disability, right foot disability, neck disability, and psychiatric disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 4. Obtain the Veteran’s VA treatment records from the Bay Pines VA Healthcare System for the period since March 2009; from the Miami VA Healthcare System for the period since December 2016; and all such relevant records from any other sufficiently identified VA facility. 5. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current cardiac disability. The examiner must opine whether any cardiac disability that has been experienced by the Veteran since approximately May 2013 at least as likely as not (1) began during active service; or (2) is related to an in-service injury or disease, including his presumed exposure to herbicide agents (including Agent Orange). The examiner must provide reasons for each opinion given. In this regard, the fact that a specific cardiac disability is not on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. 6. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current prostate disability. The examiner must opine whether any prostate disability that has been experienced by the Veteran since approximately May 2013 at least as likely as not (1) began during active service or (2) is related to an in-service injury or disease, including his presumed exposure to herbicide agents (including Agent Orange). The examiner must provide reasons for each opinion given. In this regard, the fact that a specific prostate disability is not on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. 7. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any back disability experienced by the Veteran since approximately May 2013 at least as likely as not (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (3) is related to an in-service injury or disease, including the Veteran’s back problems in May 1966, which are documented in his service treatment records. The clinician must provide reasons for each opinion given. 8. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any right foot disability experienced by the Veteran since approximately May 2013 (including, but not limited to, status post right great toe fracture and right foot drop) at least as likely as not (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis or organic disease of the nervous system); or (3) is related to an in-service injury or disease, including the Veteran’s right foot problems in September 1966 and June 1967, which are documented in his service treatment records. The clinician must provide reasons for each opinion given. 9. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to PTSD alone. (Continued on the next page)   The examiner must provide reasons for any opinion given. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Elwood, Counsel